CARDIAC RHYTHM MANAGEMNT DEVICE (CRMD)

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CARDIAC RHYTHM MANAGEMNT DEVICE (CRMD) Powered By Docstoc
					Perioperative Management Form for Cardiac Rhythm Management Devices
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Patient Name:                      Planned Procedure:

Manufacturer:                      Model:                   Serial #:              Date Implanted:

Local Rep:                Tel #:                    Cardiologist:         Tel #:



Device Type:         Pacemaker               Single lead / Dual lead
                                             Unipolar lead / Bipolar lead
                                             Biventricular
                    AICD                AICD with pacemaker

Reason for Device Implantation:
         Bradyarrhythmias                      Ventricular tachyarrhythmias             SVT            AV Block
         Sick Sinus Syndrome                   Poor LV Function                         CHF            AVN ablation



Pacemaker Settings: Mode:                   Lower Rate:          /min     Upper rate:           /min

Rate adaptive function:            No     Yes (1)

Patient's underlying rate & rhythm:                 . Is the patient pacer dependant?     Yes     No

Describe the plan for changing CRMD in a pacer dependant patient to an asynchronous mode:
Is the application of a magnet enough?       Yes           No (2)
What is the rate and mode of the CRMD when a magnet is applied? Rate:        /min    Mode:



Date of last CRMD interrogation:                    Next recommended interrogation:

Battery Life:

Describe any episodes of tachyarrhythmias recorded / shocks delivered:                     N/A

Device is in:        End-of -life mode (EOL)(3)                         Elective Replacement Indicator mode(ERI)(3)
                    Intensified Follow-up Interval mode (IFI)(4)        None of the above


Please provide any other recommendations:


Completed by:
                                                INSTRUCTIONS


   Obtain initial data from patient and scheduling surgeon / physician's office
   Forward information for detailed completion to EP physician / cardiologist / internist
   If any intervention is planned, please review with an anesthesiologist.
   The following procedures need EP physician consultation:         -RF catheter ablation
                                                                     -Lithotripsy
                                                                     -MRI
                                                                     -ECT
                                                                     -Radiation Therapy


(1) Please arrange for Rate Adaptive Function to be turned off the morning of surgery

(2) If the application of a magnet is insufficient, please arrange for reprogramming the morning of surgery. Please
    change the CRMD to an asynchronous mode at a rate of 80 Bpm.

(3) Needs replacement prior to elective surgery


(4) Needs monthly battery checks

				
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posted:10/2/2012
language:English
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